- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.13 / $892.06 / $1,200.00
| Facility | | $157.13 | $892.06 | $1,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.13 / $749.38 / $779.66
| Professional | | $157.13 | $749.38 | $779.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $799.38 / $3,538.93 / $6,994.57
| Facility | | $799.38 | $3,538.93 | $6,994.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $324.37 / $324.37 / $324.37
| Facility | | $324.37 | $324.37 | $324.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.56 / $1,571.56 / $1,571.56
| Professional | | $1,571.56 | $1,571.56 | $1,571.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.75 / $49.50 / $116.01
| Professional | | $33.75 | $49.50 | $116.01 |